Mouth Sores: A Diagnosis


EVERY SUMMER G.M. drives about eight hours north from DC and takes a ferry to the island where she spent childhood summers, and where her grown children are willing to travel many miles to join her.  But for the past few years, during the first week or longer on the island, something happens to G.M.’s mouth.

Her tongue swells and little sores develop on her tongue and the inside of her lips, making it hard to talk with extended family members—and difficult to eat.  Mealtimes are challenging. Especially unpleasant is dry, spicy or salty food, as are the first few minutes in salty ocean water that stings her mouth.

For a swollen tongue, the most obvious culprit is an allergic reaction.  Histamines flood the bloodstream—called angioedema—swell the tongue and, in severe cases, close the throat, causing life-threatening anaphylaxis.

Although G.M.’s diet on the island appears exactly the same as in DC, she always eats plenty of food on the “hypersensitivity reaction” list—in her case: nuts (walnuts and almonds), fruits and vegetables (avocados and tomatoes), milk, eggs, fish (salmon) and shellfish (lobster).  Flavorings such as cinnamon, peppermint and menthol in toothpaste as well as candy can also trigger reactions.

Discounting allergies, the causes of most other mouth issues either involve swollen tongue but no sores; or sores on the tongue —but not the lip—which make the tongue uncomfortable though not usually swollen. For most conditions, the list of causes includes stress.

At a routine checkup after her mouth recovered, G.M’s dentist was pretty set on the diagnosis of “geographic tongue,” in which the papillae or taste buds become inflamed and then disappear, causing the tongue to look red and shiny.  Splotchy bare patches on the tongue, which can look like continents on a map, can come and go, change quickly and last up to a year. Pain with geographic tongue comes from sensitivity to hot, spicy or acidic foods and to some toothpastes.

Another diagnosis candidate is “lie bumps,” or transient lingual papillitis —mythically linked to telling lies—which are painful and “extremely common” but not well understood.  Also, lichen planus is a rare rash that can itch and looks like raised red bumps or lacy, white patches. Possible causes of both include diet that is highly acidic (lots of fruits and vegetables), sugary and/or spicy; and trauma like biting the tongue.

By themselves, mouth sores (which can also cause pain in the tongue but not swelling) are most often cold sores from Herpes simplex infection; or canker sores, white or yellow sores linked to food ingredients (especially in spicy food); to vitamin deficiencies, notably vitamin B-12; and to infections.

Treatment for all mouth problems starts with what to avoid: spicy and salty food; mouthwash that contains alcohol; and toothpaste with additives, notably sodium lauryl sulphate, but also whitening agents and heavy flavoring.  The best is toothpaste for sensitive teeth—and a soft toothbrush.

Anesthetic, numbing gels can relieve mouth discomfort,  as can a rinse made with salt or baking soda.  For bumps, topical treatments can protect them with a bandage-like covering, and a paste made with baking soda or milk of magnesia can help with pain.

G.M. didn’t believe she’d found the best diagnosis, however, until her research led to “dry mouth.” Besides having a very dry mouth, symptoms include inflammation of the tongue, called glossitis; painful tongue, glossodynia; and taste disorders, dysgeusia—all of which affected G.M.

What impressed her was the inclusion of her most unpleasant and inconvenient issues: difficulty speaking as well as “swallowing and chewing —especially dry and crumbly foods such as crackers”—crackers were the worst for her.  Also important was the increased need to drink water, especially at night.

When salivary glands aren’t working well enough to keep the mouth moist, xerostomia is most often linked to side effects of medications, including the Wellbutrin G.M. takes.  For most who take the offending medications, dry mouth is a small price to pay.

Dry mouth is also a symptom for systemic conditions such as hypothyroidism and Parkinson’s disease as well as autoimmune diseases, such as Sjogren’s syndrome, diabetes, lupus and rheumatoid arthritis.

But in G.M.’s case, the biggest offender may be what she does on any long car ride.  She drinks as little as possible to avoid needing extra bathroom breaks.  To stave off sleepiness, she skips meals, instead eating a variety of chocolates, a granola bar, popcorn, and maybe an apple—while specific advice for dry mouth sufferers includes “decreasing your fermentable carbohydrate intake, especially for sticky foods such as cookies, bread, potato chips, gums, candies.”

Another trick to help stay awake—and because late July temperatures on the drive are always over 90 degrees—she turns up the air-conditioner fan, which produces very dry air.  And then there’s the stress of packing and driving—as well as the immense relief brought by drinking cool liquids and sucking ice chips, which is a mouth-discomfort remedy advised mostly in cases of dry mouth.

Adequate saliva is important not only to aid chewing and swallowing but also to enhance the ability to taste; its enzymes aid in digestion; and it helps prevent tooth decay.

For dry mouth in particular, remedies focus on increasing saliva with chewing gum or mints—preferably those containing Xylitol to avoid sugar—as well as using mouthwashes and sprays, especially during the night and whenever drinking excess water is inconvenient.  Among favorite recommendations for G.M. are breathing through the nose, also good for reducing stress; and eating carrots.

G.M.’s dentist agreed that her collection of symptoms was intriguing —“your teeth look fine, but this is exciting”—and suggested she consult an unfamiliar specialty, oral medicine, when her condition returns.

That condition occurs, however, only on an island with no specialists at all, even a dentist.  Meanwhile, she has stocked up on dry-mouth products, including Sensodyne True White toothpaste, Oasis spray for nighttime, and Xylitol-containing Spry Gems mints and Biotene lozenges —and she has more to try.  She also plans to change her driving routine, or at least to skip the popcorn.

—Mary Carpenter

Every Tuesday, well-being editor Mary Carpenter reports on health news you can use.



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